Developing partnerships with local EMS providers to decrease door-to-balloon timesSummary The American College of Cardiology guidelines for “door-to-balloon” time identify evidenced-based practice as less than 90 minutes for patients experiencing a heart attack and “door to door-to-balloon” time as less than 120 minutes. Initial data collection revealed that our hospital was experiencing door to door-to-balloon times of up to 240 minutes with an average of 146 minutes. Analysis of the process showed that patients calling for emergency response would be brought to the nearest emergency department (ED) (i.e., the first “door”) and subsequently transferred out to a facility (the second “door”) capable of performing percutaneous coronary intervention (PCI). The problem was clearly identified as delays in getting the patient to an interventional hospital for immediate treatment. Our project focused on reducing the door to door-to-balloon time to less than 120 minutes by eliminating the first “door.” This would be accomplished by identifying the ST-elevation myocardial infarction (STEMI) on-site in the community where the patient is assessed by the community Emergency Medical Services (EMS), and working collaboratively and efficiently with both the non-interventional and the interventional facilities to get the patient into PCI treatment immediately. The overall goal for this project was to develop and implement a Field STEMI Program that would meet or exceed a target of “field EKG-to-balloon time” of 90 minutes or less. Success of the project would require coordination and strong collaboration with community EMS responders (both land and air), hospital EDs and ED physicians from potential referring facilities as well as our interventional facility, all cardiologists, the cardiac cath lab, admissions department, and the coronary care unit facilitators. During the performance improvement process, our multi-disciplinary team designed a patient flow where EMS coordinates with the ED physician, who confirms the patient is actively having a heart attack and instructs the EMS unit to divert transport to the interventional facility. The physician also instructs the paramedic to follow the STEMI protocol for treatment and medication therapy. The interventional facility is alerted and prepares for the patient’s immediate arrival. Because of the collaborative team approach and through building strong relationships with community services, we were able to identify and correct potential problems, and design a successful field STEMI program that positively impacts the outcomes of heart attack victims seeking emergency treatment. Our goal of achieving a field EKG-to-balloon time of 90 minutes or less has been achieved 100% of the time! As a result of early identification and coordination, our average door-to-balloon time for Field STEMI patients is 27 minutes, drastically exceeding the 90-minute standard set by the American College of Cardiology (ACC). An additional improvement that we recognized was the time from 911 dispatch to balloon (PCI) time, also less than the 90-minute target. This innovative process focuses on the desired end result even before EMS arrives. As soon as the 911 call is received, the coordination begins. Assessment of geographic location and traffic is required in the decision-making process for transport to the interventional facility by land or air. As a result of this project, we learned the importance of having involvement from all stakeholders, especially community support. Project Selection The Field STEMI project started December 2007 with a desire to save lives by saving the heart muscle of individuals in the community seeking emergency treatment for potential heart attack. Understanding that every minute counts when a patient’s coronary artery is depriving the heart of vital blood and nutrients during a heart attack is what inspired process improvement for our organization. Because WellStar Cobb is a referral center for WellStar Douglas, we have to not only focus on patients that come into our own ED, but also on patients that enter referring facilities to have a positive impact on all the communities we serve. The first Field STEMI initiative focused on Douglas County, which is over 200 square miles, and the 911-responders, the Douglas County Fire Department. Data for our door to door-to-balloon times revealed a longer than acceptable standard. Our average door to door-to-balloon time was 146 minutes, exceeding ACC requirements by 26 minutes. Goal The goal of the Field STEMI project was to reduce door-to-balloon time to less than 120 minutes by eliminating the first “door” (i.e., the act of taking the patient to the nearest ED, regardless of the facility’s interventional capabilities). The overall goal for this project was to develop and implement a Field STEMI Program that would meet or exceed a target of field EKG-to-balloon time of 90 minutes or less. Literature review and best practice studies indicated that we must change the practice of EMS taking patients to hospitals that are not capable of performing PCI, thus bypassing that first “door.” Instead, EMS must work with the initial and the PCI treatment facilities to divert transport to the PCI facility, ensuring that heart attack victims receive immediate interventional treatment. This is accomplished by the first and usually nearest ED working with the community EMS to diagnose the patient with a field EKG. By adopting this process, a more efficient rescue and care delivery system would be achieved through: 1. Eliminating the timely process of unloading the patient at the first facility; 2. Eliminating triage and admission to the first facility; 3. Providing immediate assessment in the field; 4. Eliminating wait times for transport to a PCI facility; 5. Eliminating time delays in reloading patient in EMS for transport. All of these process changes would reduce door-to-balloon times by 30 minutes or more. Improvement Process The implementation of the Field STEMI Project began by approaching the hospital’s foundation for funding. The foundation is responsible for raising funds for the hospital system since we are a not-for-profit organization. After presenting the information about the project, including potential community benefits and the project plan, the foundation board approved the purchase of transmission modems and service for the local EMS trucks. The modems allow acquisition and transmission of 12-lead electrocardiograms that diagnose a STEMI. Obtaining support for the project included identification of key stakeholders and bringing them to the table, where best practice processes could be studied and gaps in performance among the various care processes identified. Achievable goals were set and the collaborative improvement process began. Discussions regarding potential barriers to success were addressed, ideas for improvement were shared and project plans were developed. It was imperative that we enlist the cooperation and support of EMS responders (both land and air), ED and ED physicians at both WellStar facilities, all cardiologists, the cardiac cath lab, admissions department, and the coronary care unit facilitators. Opportunities for improvement were identified by studying and challenging the processes — then strategically planning and implementing methods of performance improvement. Throughout the project, all levels of leadership from each division of service were involved and committed to expediting treatment of STEMI victims in our communities. The team, along with leadership engagement, designed a basic improvement plan with key process steps, assigned responsibilities and target dates. The plan involved acquiring and transmitting an EKG, obtaining physician diagnosis of STEMI, diversion to a PCI facility, and alerting the cath lab and interventional cardiologist for immediate treatment. Additional plans included early admission by the treatment facility prior to patient arrival, which would facilitate immediate access to medication upon arrival. We developed checklists to consistently implement each step of the process as well as data collection tracking sheets to identify inefficiencies. Each leader agreed upon the responsibilities for each of their departments and provided appropriate education to staff to ensure knowledge and skills required for successful patient flow and medical care. The team also developed the STEMI protocol for assessment and treatment to be utilized by the local 911 responders. Extensive education and training plans were developed and implemented for the EMS responders. These included several classes on 12-lead EKG interpretation as well as medication administration. Admissions developed an entirely new system for patient admission prior to arrival to the hospital. Additional equipment was purchased and installed in the EDs that enabled transmission and receipt of field EKGs. When members of the team agreed that adequate training, competency assessments and other preparations were completed, three random test trials were planned and implemented. One of the test trials included the need for helicopter transport. The test plans also included 911 dispatch to different areas of the community, including remote areas at high traffic times. When 911 dispatches local EMS responders, a geographic and traffic assessment takes place. This assessment may trigger the EMS to send an alert to the flight crew. When ground transport to interventional facility is delayed, EMS coordinates with the flight crew and prepares a landing zone for emergency transport. The ED receives a “STEMI Alert,” called over the Hear Radio to prepare for receiving a 12-lead EKG, immediately given to the physician for confirmation. Once a confirmed STEMI, the patient is diverted to the interventional facility. For efficiency and accuracy, a single contact number is utilized for the ED at the receiving facility to notify the PCI treatment facility. The STEMI facilitator who receives the call is responsible for alerting the interventional cardiologist, the cath lab staff on call and admissions. The facilitator will meet the EMS responders at the door of the ED and direct patient flow. Patients are directed to the cath lab for emergent intervention. Results/Outcomes Starting patient care in the community at first contact with EMS has resulted in an average field EKG-to-balloon (reperfusion) time of 62 minutes, and is continually improving. Ongoing measurement results of field EKG-to-balloon time of less than 90 minutes have been met 100% of the time from the launch of the project-to-date, which far exceeds our overall expectations! Community benefit also exceeded expectations, as indicated by our results. After strategic planning and testing, the process proved to work very efficient, demonstrated by an actual 911 alert triggering the new protocol for our first patient that went out to the EMS dispatching for a chest pain victim in our community. A 12-lead EKG was transmitted to the local facility and diagnosed as a STEMI with instructions to transport to the interventional facility. Each step of the process worked in sequence through collaborative efforts. The time elapsed from qualifying EKG to reperfusion was 73 minutes. Fortunately for this patient, our new Field STEMI process with transfer method was in place, because this patient’s condition deteriorated upon arrival, requiring multiple shocks, temporary pacing and intra-aortic balloon pumping. This was a case of the right care at the right place at the right time. During a follow-up visit with this patient, he stated: “I’m glad you were able to get my heart attack fixed so quickly, so I could have this Christmas with my granddaughter.” This is just one example of a truly rewarding experience that could be shared with the team and staff, thus enabling them to realize the personal as well as clinical impact of the project. The greatest impact of this project is related to patient outcomes. The national standard is 90 minutes or less from door to balloon. Evidence-based research indicates that treatment received within that small window of time increases the patient’s chance of survival. The Field STEMI Project ensures that our patients receive treatment well within that window as we consistently exceed national targets. Of the greatest importance, the project has resulted in saving lives. Community members within our service area now have the very best chance of surviving a STEMI and decreasing the risk of permanent heart damage. This clearly demonstrates a commitment to the vision and mission of our organization in providing world-class healthcare and improving the health and well-being of the individuals we serve, one patient at a time. Innovation The Field STEMI project offers quick and accurate EMS assessment of potential heart attack victims, followed up with an ED physician to properly diagnose and direct to the appropriate facility within the critical time frame. In the past, the standard practice was to take patients to the nearest ED that provided cardiac care, then transfer to a PCI treatment facility if needed, thus creating two separate “door” times. Our project also focused on identifying how we could make a difference in saving lives starting in the field and prior to arrival at the hospital. Bringing together a multi-disciplinary team to strategically plan and implement the Field STEMI Program challenged the traditional standard of care for STEMI patients within the community. Instead of EMS transporting patients to the closest facility, they now transport to the closest interventional facility, after field EKG and consult with an ED physician confirms a STEMI. Results soon showed that time from 911 dispatch to balloon (PCI) time was less than 90 minutes, an even greater improvement than expected. Knowledge Sharing We have been able to share the outcomes with other healthcare professionals as well as members of the community. Ongoing feedback is shared regarding the positive impact of the response team, including pictures of the coronary artery before and after intervention. Internally, the PCI team meets weekly to ensure that outcomes are sustained so we can provide the right care at the right place, every time. Status reports on team progress, as well as data outcomes and analysis, are reported regularly throughout the hospital quality structure at the hospital Cardiology PI Committee and the Quality Review Committee. For any facility considering implementing a similar community performance improvement project, we found that the most important factor is active involvement of the entire team. Embrace the experience, knowledge, and expertise of each team member to plan a process that’s right for your community and your institution. The authors can be contacted at: Renee.Akins-Becker@wellstar.org Sharon.Ellis@wellstar.org
American College of Cardiology, STEMI Guidelines. Available at: http://www.acc. org/qualityandscience/clinical/guidelines/steMI/. Accessed August 2, 2008.